Provider Demographics
NPI:1093775942
Name:JOHNSON, SCOTT S (MD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-495-4577
Mailing Address - Fax:602-417-3549
Practice Address - Street 1:2400 EDISON ST
Practice Address - Street 2:
Practice Address - City:BRUSH
Practice Address - State:CO
Practice Address - Zip Code:80723-1642
Practice Address - Country:US
Practice Address - Phone:970-842-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO23245207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C804194Medicare PIN
D24240Medicare UPIN
80528Medicare ID - Type Unspecified